I dialed the number while sitting in my garage, because it was 5 PM, and that’s the time of day when my house “kinda sounds like someone is being murdered over there.” (in the words of one hilariously honest resident)
But the background chaos didn’t matter.
Nobody answered. I let it ring for an eternity, as I had been doing. Nobody was going to answer.
Our patient had days, maybe hours – the list of what could happen to cause them to suddenly decompensate was a mile long, and included “Rupture of known varices in setting of multifactorial coagulopathy”
We knew this was coming, they knew it was coming – the only thing that was uncertain was when their family would arrive.
A month ago, it was the 20th. A week ago, it was Thursday.
The barely there, tarnished silver lining to this scenario is that we all had time. The conversations had taken place – the ones held after hours when the commotion of the wards has quieted and there’s that still quality that lends itself to answering hard questions. The kind that leave you with drying sweat under your white coat once you walk out of the room, the physically palpable emotion still hanging in the air.
So once our patient had made peace with what their diagnosis meant, what things would come to pass despite all our best efforts, everyone planned for It – planned for the change-over to comfort care and DNR once papers were signed and affairs settled.
But y’all know the one about best laid plans, right?
Wednesday, both the brother and Dad would answer the phone, to answer questions and give updates. After the no-show on Thursday, the brother would still answer, but we couldn’t reach the Dad – who our patient had been so desperate to see for the last month, going through increasingly painful days and treatments to buy them those last weeks. After Saturday and still nobody arriving, the brother wouldn’t answer either.
We as doctors have the opportunity to know someone more intimately than their own family – but in so many other ways, we don’t know them at all – we have no clue about missed events, or broken promises – or why family may decide they can’t make it to sit vigil over a deathbed.
And so Sunday night I gave the word. Yes, they were full code. We had promised not to change their status before family got there. But the knowledge that it was futile care was spread amongst the night code team – I explained how they could try and do the least harm to the patient at the end. If any one of the many complications set it, even heroic efforts would not bring them back.
As the sun was just starting to rise Monday morning. The Call Came. I scrambled up from the couch cushions where sleep had finally come between notes, calls from the ER and refreshing vital signs.
The night intern, who is known for his wit and great big grin… “Uh, it’s about, ah… 4502.”
Medical Trivia: Sinus pause is a medical condition wherein the sinoatrial node of the heart transiently ceases to generate the electrical impulses that normally stimulate the myocardial tissues to contract and thus the heart to beat.
“I just wanted to make sure that you wanted them to be DNR and comfort measures only. Their Family is here, and they’re ok with it.”
Our last ditch efforts had worked. They had even been awake enough to talk for awhile, cracked a few jokes before lapsing back into sleep.
We could not beat splanchnic dilation in the setting of advanced liver failure. But we got them time, enough to say goodbye.